Comprehensive Respiratory Requisition

Patient Information

Patient Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Phone Number

Sex *

Passport Number

Physician Iinformation

Requesting Physician Signature *

Specimens will not be processed without a Health Care Provider's signature and ICD-10 code

Collection Information

Date Collected *

Time *

Collection Site *

Parent/Guardian Consent for ALL patients under 18 Y.O. to Receive Test Results via Text and / or Email

Parent/Guardian Name *

First

Last

DOB:

Phone

Email *

Race & Ethnicity

race

Billing Information (please attach copies of all cards, front and back)

Primary *

Insuance Carrier:

Policy / ID Number

Group Number

Note: the following diagnosis codes are listed as a convenience only. Ordering physicians are REQUIRED to use the ICD-10 code that best describes the reason for performing the test, whether or not that code is listed below.

Specimen Submitted

Collection Type

Nasopharyngeal
Nasal
Oropharyngeal
Saliva

COVID-19 (PCR)

Z20.822 Contact with and (suspected) exposure to COVID-19
Z86.16 Personal history of COVID-19
U07.1 2019-nCoV Acute Respiratory Disease
J12.82 Pneumonia due to Coronavirus Disease 2019
Other

Other Test *

RSV Only
Flu A/B Only
Flu A/B & RSV

COVID-19 ANTIGEN

Z20.822 Contact with and (suspected) exposure to COVID-19
Z86.16 Personal history of COVID-19
U07.1 2019-nCoV Acute Respiratory Disease
J12.82 Pneumonia due to Coronavirus Disease 2019
Other

Bacteria
• Campylobacter (jejuni, coli, and upsaliensis) • Clostridium difficile (toxin A/Bl • Plesiomonas shigelloides • Salmonella • Yersinia enterocolitica • Vibrio (parahaemolyticus, vulnificus, and cholerae) • Vibrio cholerae Diarrheagenic E. coli/Shigella • Enteroaggregative E. coli (EAEC) • Enteropathogenic E. coli (EPEC) • Entertoxigenic E. coli (ETEC) It/st • Shiga-like toxin·[Jroducing E. coli (STEC) six l / stx2 • E.coli0157 • Shigella/Enteroinvasive E. coli (EIEC)

Parasites
• Cryptosporidium • Cyclospora cayetanensis • Entamoeba histolytica • Giardia lamblia

Viruses
• Adenovirus F40 / 41 • Astrovi rus • Norovirus GI/GIi • Rotavirus A • Sapovirus (I, II, IV and V)

Respiratory (SYMPTOM) ICD-10 *

COVID-19 (Antibody)

lgG/lgM

For Lab Use Only

SWAB G2023 Specimen collect COVID-19

SPECIMEN REQUISITION & LABEL INSTRUCTIONS:

1. Fully complete requisition form witli all required information.
2. Complete specimen label with patients date of birth and full name.
3. Remove label and place bar coded label VERTICALLY on the specimen vial (not on the lid).

* Please ensure the patients date of birth and full name is indicated so that both the label and requisition match. Two patient identifiers are required on each specimen submitted. The unique barcode identifies the patient with this requisition form.

FOR UNINSURED PATIENTS: If you want A2Z Diagostics to bill the CARES ACT Provider Relief Fund for uninsured patients, you MUST provide the following information.

Patient Social Security
State Driver License
State ID

I have verified and attest to the best of my knowledge that this patient does not have coverage through an individual, employer-sponsored plan, Federal Employee Health Benefits Program, federal health program, Medicare or Medicaid, and no other payer will reimburse for COVID-19 antibody testing at the time the test was ordered:

Yes
No